Craniofacial Anomalies, Part 2 - Plastic Surgery Internal

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Fig 24. Interocular distance measured from inner canthus to inner canthus. A, normal. B, primary telecanthus. C, true ocular hypertelorism. D, ocular hypertelorism with secondary telecanthus. (Reprinted with permission from Cohen MM Jr, Richieri-Costa A, Guion-Almeida ML, Saavedra D: Hypertelorism: interorbital growth, measurements, and pathogenetic considerations. Int J Oral Maxillofac Surg 24:387, 1995.) osteotomy mobilizing the lateral, inferior, and medial orbital walls as a single bloc. The maximum correction that is possible with medial orbital wall mobilization is 10mm; with a U-shaped osteotomy, 15mm. The intracranial approach as described by Tessier 368,369 with Converse’s modification 433 is preferred in all severe cases of hypertelorism or when the cribriform plate lies below the level of the frontonasal suture (Fig 26). The entire orbit is mobilized as a box, providing total control of the intracranial contents. McCarthy and colleagues 434 report correction of orbital hypertelorism on 20 children age
SRPS Volume 10, Number 17, Part 2 Fig 26. Above, one-stage medial orbital osteotomy with preservation of the cribriform plate. Below, subtotal orbital osteotomy with preservation of the cribriform plate. (Reprinted with permission from Converse JM, Wood-Smith D: An atlas and classification of mid-facial and craniofacial osteotomies. In: Transactions of the Fifth International Congress of Plastic and Reconstructive Surgery. Melbourne, Feb 1971, p 931.) Anophthalmia and Microphthalmia Anophthalmos and microphthalmos represent failure of optic development. Absence or diminutive size of the eyes fails to stimulate orbital growth and results in orbital hypoplasia. Kennedy437 elicited hypoplasia of the orbit by ocular enucleation during embryogenesis in cats. The classic treatment for orbital hypoplasia secondary to anophthalmia or microphthalmos has been the insertion of progressively larger silicone orbital implants covered by scleral shells. This treatment has met with only moderate success due to difficulty in maintaining the implants and the need for frequent readjustments. Tessier438 enlarged the orbit by a lateral osteotomy that allowed expansion of the orbital volume inferiorly and laterally. Marchac439 later added a supraorbital craniectomy and frontal craniotomy that relocated the orbital roof and allowed expansion of the orbital volume in three directions. Elisevich and colleagues440 subsequently 40 described a technique for 3D expansion of the orbit without craniotomy using a single burr-hole craniectomy of the frontosphenoid bone. Working from the basis that orbital hypoplasia is the consequence of an inadequate stimulating matrix, Lo et al 441 demonstrated the effectiveness of subperiosteal tissue expanders in the bony orbit to substitute for the missing stimulus. They enucleated one eye in 12 6-week-old kittens and placed subperiosteal tissue expanders in half of the orbits; the other 6 served as controls. All the orbits in which tissue expanders were placed demonstrated equal or greater orbital volumetric measurements than normal orbits, compared to enucleated orbits that did not receive tissue expanders, whose measurements were significantly lower than the normal. Rodallec and coworkers 442 report the use of silicone expanders in 17 patients. The expanders were placed within the intramuscular cone to expand not only the bony orbit but also the soft tissues. SURGERY ON THE MAXILLA Le Fort I Osteotomy The Le Fort I osteotomy is a horizontal osteotomy of the upper jaw at the level of the (Le Fort I) fracture line. It was initially described by von Langenbeck in 1859 and used widely in the second half of the 19th century to temporarily mobilize the maxilla for better access to tumors and polyps. Not until the 1960s, however, did mobilization of the maxilla become generally accepted, due in large measure to the precise operative technique and superb results reported by Obwegeser, 373 who demonstrated that it was possible to fully mobilize the maxillary segments and bring them into the desired position without softtissue resistance for primary stabilization. 443 Obwegeser also described a higher maxillary osteotomy (Le Fort I½) for use in patients with pronounced midfacial recession to advance the retruded portion of the maxilla lateral to the piriform aperture. Other modifications of the Le Fort I osteotomy have been described, including a self-stabilizing osteotomy suggested by Munro—a “self-retained Le Fort I”. 444 Many authors have confirmed tooth viability subsequent to Le Fort I osteotomy, with reinnervation of the pulp over a period of several months. 445,446
Page 2 and 3: CRANIOFACIAL EMBRYOLOGY To understa
Page 4 and 5: CENTRIC Corresponding Cranial Facia
Page 6 and 7: visceral arches, the intervening fi
Page 8 and 9: The Treacher Collins syndrome66 rep
Page 10 and 11: Fig 5. (Above) The nose and upper l
Page 12 and 13: Fig 8. Left, child with asymmetrica
Page 14 and 15: Fig 10. Cranial sutures in the huma
Page 16 and 17: Approximately 2% of cases of isolat
Page 18 and 19: tosis usually have normal mental de
Page 20 and 21: Fig 14. Technique for correction of
Page 22 and 23: SRPS Volume 10, Number 17, Part 2 F
Page 24 and 25: mutations implicated in the cranios
Page 26 and 27: Pfeiffer syndrome is inherited as a
Page 28 and 29: Associated Anomalies Although cervi
Page 30 and 31: • The transfacial approach330 may
Page 32 and 33: Relative indications for decompress
Page 34 and 35: traces the patients’ course over
Page 36 and 37: tomical correction of the deformiti
Page 38 and 39: TABLE 7 Brain Growth During the Fir
Page 42 and 43: Le Fort II Osteotomy The Le Fort II
Page 44 and 45: 0 and 7 days. This would suggest th
Page 46 and 47: inconvenience to the patient and th
Page 48 and 49: SRPS Volume 10, Number 17, Part 2 F
Page 50 and 51: lengthening was 16.8mm in the mandi
Page 52 and 53: 1. Sperber GH: Craniofacial Embryol
Page 54 and 55: 85. Dufresne C: Treacher Collins Sy
Page 56 and 57: 169. Opperman LA, Chhabra A, Cho RW
Page 58 and 59: 247. Sutton LN, Barlett SP, Duhaine
Page 60 and 61: 334. Colen SR: Selective microvascu
Page 62 and 63: 420. Tessier P: Dysostoses cranio-f
Page 64: 503. Kunz C, Hammer B, Prein J: Man

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